1. HEART FAILURE TEAM MEMBERSHIP DEPARTMENTS OF CARDIOLOGY, CARDIOVASCULAR SURGERY, MEDICINE, NURSING, QUALITY AND RESOURCE MANAGEMENT, THE CENTER FOR CLINICAL EFFECTIVENESS, MEDICAL RECORDS, INFORMATION TECHNOLOGIES, EPIC PROJECT COORDINATORS CARMEN BARC, RN, BSN SARAH BORN, RN, BSN CONFIDENTIAL-FOR QUALITY IMPROVEMENT PURPOSES ONLY

2. OPPORTUNITY STATEMENT Improve the quality of care for heart failure patients by providing evidence- based treatment as outlined in the Heart Failure Core Measures CONFIDENTIAL-FOR QUALITY IMPROVEMENT PURPOSES ONLY

3. Heart failure accounts for more hospital admissions than any other Medicare diagnosis. Research shows that the following care processes decrease morbidity and mortality rates for heart failure patients*: Left ventricular systolic function (LVSF) assessment Angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) prescribed for left ventricular systolic dysfunction (LVSD). Ejection fraction (EF) <40% or description of moderate/severe dysfunction. Written discharge instructions regarding activity, diet, follow-up, medications, symptoms worsening, and weight management Smoking cessation counseling for patients who have smoked within the last twelve months Our goal is to achieve 100% compliance to these measures. *Heart Failure Society of America. HFSA 2006 Comprehensive Heart Failure Practice Guidelines CONFIDENTIAL-FOR QUALITY IMPROVEMENT PURPOSES ONLY

4. FORCES OF MAGNETISM Force 6: Quality of Care Force 7: Quality Improvement Force 9: Autonomy Force 11: Nurses as Teachers Force 13: Interdisciplinary Relationships CONFIDENTIAL-FOR QUALITY IMPROVEMENT PURPOSES ONLY

5. 2008 INTERVENTIONS Cardiac rehab documentation tool incorporated into EPIC Involved cardiac research nurses in the heart failure initiative Developed and provided physicians with core measure pocket cards Inserviced 5T nursing staff (new unit/new staff) on the Heart Failure core measures Redistributed Heart Failure core measure pocket cards to nursing staff CONFIDENTIAL-FOR QUALITY IMPROVEMENT PURPOSES ONLY

6. Definition: Number of heart failure patients receiving 100% of indicated care / all heart failure patients Data Source: Original data extracted from LUMC charts by RNs. Analysis: The number of LUMC patients with Heart Failure who receive all indicated care significantly decreased in November and December 2006 due an EPIC issue that negatively affected documentation of discharge instructions. This issue has been resolved and performance now is significantly improved over baseline. CONFIDENTIAL-FOR QUALITY IMPROVEMENT PURPOSES ONLY

7. Definition: HF patients with documentation in the hospital record that left ventricular function (LVF) was assessed before arrival, during hospitalization, or is planned for after discharge / All HF Patients. Datasource: Original data extracted from LUMC charts by RNs. Analysis: LUMC performance has been above 97% since January 2006. CONFIDENTIAL-FOR QUALITY IMPROVEMENT PURPOSES ONLY

8. Definition: Heart Failure patients who are prescribed an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) at hospital discharge / HF patients with LVSD and without contraindications. LVSD is defined as chart documentation of a left ventricular ejection fraction less than 40% or a narrative description of left ventricular function consistent with moderate or severe systolic dysfunction. Prior to 2005, ARBs were not recognized in compliance with this measure. Datasource: Original data extracted from LUMC charts by RNs. Analysis: LUMC performance has been at 100% since May 2007. CONFIDENTIAL-FOR QUALITY IMPROVEMENT PURPOSES ONLY

9. Definition: HF patients with documentation that they or a caregiver received discharge instructions (weight monitoring, what to do if symptoms worsen, diet, medications, activity level, follow-up appointment) prior to hospital discharge / HF patients discharged to home. Data Source: Original data extracted from LUMC charts by RNs. Analysis: A technical issue with the electronic medical record lead to a decline in this measure. This was resolved starting with January 2007 discharges, and performance has improved significantly. CONFIDENTIAL-FOR QUALITY IMPROVEMENT PURPOSES ONLY

10. Definition: Smokers receiving smoking cessation counseling / HF Patients who have smoked cigarettes at any time in the 12 months prior to hospital arrival. Data Source: Original data extracted from LUMC charts by RNs. Analysis: LUMC performance has been nearly perfect since March 2006. CONFIDENTIAL-FOR QUALITY IMPROVEMENT PURPOSES ONLY

11. NEXT STEPS Require a complete discharge medication list in the medical record for all inpatient heart failure discharges Incorporate revised discharge instructions into EPIC discharge navigator Ongoing multidisciplinary education and feedback CONFIDENTIAL-FOR QUALITY IMPROVEMENT PURPOSES ONLY